ORTHOPEDIC SPORTS MEDICINE RADIOLOGY REFERRAL REQUEST€¦ · MRI CT Nuclear Medicine Wave...
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www.radnet.com ORTHOPEDIC SPORTS MEDICINE RADIOLOGY REFERRAL REQUEST To Schedule - P: (949) 387-5000 | F: (949) 753-9030 Tax ID# 954651287 NAME: DATE: DOB: Reason for Exam: Pre-Authorization Required (Clinical Notes Attached) MAGNETIC IMAGING (MRI) No Contrast With/Without Contrast No Contrast With/Without Contrast Tagged WBC Other: ___________________ ___________________ ___________________ Whole body 3 Phase Venous duplex MSK Arthrogram 1.5 Tesla magnet requested 3 Tesla magnet requested 1.2 Tesla (Open Magnet) Coronal / Sagittal reconstruction views 3D reconstruction views (if available) Protocols: Mako Prophecy Conformis Other: ______________ BONE SCAN X-RAY COMPUTERIZED TOMOGRAPHY (CT) ULTRASOUND KNEE RIGHT LEFT Lumbar Cervical Thoracic SHOULDER HAND WRIST ELBOW HIP ANKLE Forefoot SPINE OTHER Please Indicate Special Instructions History: Prior Surgery: Physician’s Signature: MemorialCare - Newport Beach/Invision MemorialCare - Saddleback Valley WAVE - Laguna Woods WCR - Mission Viejo Orange Advanced Imaging Garden Grove Advanced Imaging Anaheim Advanced Imaging WCR - Santa Ana/WAVE Interventional MemorialCare - Huntington Beach MemorialCare - Fountain Valley (See location/address on reverse side of this form) MemorialCare - San Clemente MemorialCare - Irvine West Coast Radiology - Irvine ORTHOPEDIC_SPORTS_MEDICINE_REV09232019VER1MC
Transcript of ORTHOPEDIC SPORTS MEDICINE RADIOLOGY REFERRAL REQUEST€¦ · MRI CT Nuclear Medicine Wave...
www.radnet.com
ORTHOPEDIC SPORTS MEDICINERADIOLOGY REFERRAL REQUEST
To Schedule - P: (949) 387-5000 | F: (949) 753-9030 Tax ID# 954651287
NAME: DATE:
DOB:
Reason for Exam:
Pre-Authorization Required (Clinical Notes Attached)
MAGNETIC IMAGING (MRI)
No Contrast
With/Without Contrast
No Contrast
With/Without Contrast
Tagged WBC Other:_________________________________________________________
Whole body
3 Phase Venous duplex
MSK
Arthrogram
1.5 Tesla magnet requested
3 Tesla magnet requested
1.2 Tesla (Open Magnet)
Coronal / Sagittal reconstruction views
3D reconstruction views (if available)
Protocols:
Mako
Prophecy
Conformis
Other: ______________
BONE SCAN X-RAY
COMPUTERIZED TOMOGRAPHY (CT)
ULTRASOUND
KNEE
RIGHT LEFT
Lumbar Cervical Thoracic
SHOULDER
HAND
WRIST
ELBOW
HIP
ANKLE Forefoot
SPINE
OTHER
Please Indicate Special Instructions
History:
Prior Surgery:
Physician’s Signature:
MemorialCare - Newport Beach/Invision
MemorialCare - Saddleback Valley WAVE - Laguna Woods WCR - Mission Viejo
Orange Advanced Imaging Garden Grove Advanced Imaging
Anaheim Advanced Imaging
WCR - Santa Ana/WAVE Interventional
MemorialCare - Huntington Beach MemorialCare - Fountain Valley
(See location/address on reverse side of this form)
MemorialCare - San Clemente
MemorialCare - Irvine West Coast Radiology - Irvine
ORTHOPEDIC_SPORTS_MEDICINE_REV09232019VER1MC
www.radnet.com Tax ID# 954651287Thank you for choosing our Imaging Centers.ORTHOPEDIC_SPORTS_MEDICINE_REV03252020VER1MC
Locations, Maps & General Information
GENERAL INFORMATION:
1. IT IS REQUIRED THAT WE HAVE A DOCTOR’S ORDER TO PERFORM YOUR EXAM.
2. Please bring a valid ID card with you along with your insurance card.
3. Some exams require authorization.
4. Please plan on completing registration forms prior to your exam.
5. If possible, dress in loose, comfortable, two-piece clothing. For MRI exams, no belts, or zippers and leave your valuables at home.
prior exam reports/images needed for comparison.
7. Study times may vary
Leading Radiology Forward.TM
Anaheim Advanced Imaging
Garden Grove Advanced Imaging
West Coast Radiology Irvine
Orange Adv./ Orange Imaging Center
West Coast Radiology Santa Ana
Wave Imaging Laguna Woods
947 S Anaheim Blvd, #130, Anaheim CA 92805
9191 Westminster Ave, #105, Garden Grove CA 92844 | BLWI #210
16300 Sand Canyon Ave, #102, Irvine CA 92618
230 S Main St, #101, #205, Orange CA 92868 | BLWI #100
1100-A N Tustin Ave, Santa Ana CA 92705
27882 Forbes Rd, #120, Laguna Niguel CA 92677
714-758-9800
714-583-6314
949-753-0900
714-288-5400
714-835-6055
949-272-2200
24301 Paseo De Valencia #100, Laguna Woods, CA 93637 949-462-3999
= Open System = 3T MRI = 1.5T MRI
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Wave Interventional Radiology & Imaging Center 999 N. Tustin Avenue, #5, Santa Ana, CA 92705 657-232-1572
MemorialCare - Huntington Beach 17762 Beach Blvd., #110, Huntington Beach, CA 92647 714-898-2991
MemorialCare - Fountain Valley 18785 Brookhurst St., #102, Fountain Valley, CA 92708 714-417-9950
MemorialCare - Newport Beach 3300 West Coast Highway, #B, Newport Beach, CA 92663 949-646-4400
Invision - Newport Beach 280 Newport Center Dr., #100, Newport Beach, CA 92660 949-706-2000
MemorialCare - Irvine 4050 Barranca Pkwy., #160, Irvine, CA 92604 949-726-9500
West Coast Radiology Mission Viejo
675 Camino De Los Mares, #101, San Clemente, CA 92673 949-493-8799
Saddleback Valley Radiology 23961 Calle De La Magdalena, #243, Laguna Hills, CA 92653 949-855-4301
MemorialCare - San Clemente
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ORANGECOUNTY
LOS ANGELESCOUNTY
LOS ANGELESCOUNTY
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3 4/5
1413
Cleme
LagunaBeach
Irvine
Fullerton
NewportBeach
HuntingtonBeach
LongBeach
BuenaPark
Lakewood
Los Angeles
DanaPoint
GardenGroveSeal
Beach
Compton
SantaMonica
Downey
YorbaLinda
SantaAna
Torrance
ManhattanBeach
LagunaHills
MissionViejo
Brea
LagunaBeach
Irvine
Fullerton
NewportBeach
HuntingtonBeach
LongBeach
BuenaPark
Lakewood
Los Angeles
DanaPoint
GardenGroveSeal
Beach
Compton
SantaMonica
Downey
YorbaLinda
SantaAna
Torrance
ManhattanBeach
LagunaHills
MissionViejo
Brea
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67
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15
8
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N
S
EW
5 Miles
10 Miles
O = Open System 1.2O*
3T
3T
3T 1.5
3T
3T
3T
1.53T
1.5
1.5
1.5
1.5
1.5
1.5
1.5
1.5
O
O*
